Tuberculosis Associated Pancytopenia After Kidney Transplantation

摘要

A case of renal transplant patient with disseminated tuberculosis presented as pancytopenia is reported here confirming the diagnostic difficulties. A 36 year old male received the first kidney transplant from his father in February, 1988, after 8 months of regular hemodialysis treatment (unknown underlying renal disease). Triple immunosuppressive therapy (azathioprine, prednisolone and cyclosporine A) had been used until the outbreak of the Bosnian war in 1992 when he immigrated to Serbia. He has been living in a refugee camp, discontinued his regular check up and cyclosporine therapy. In March 1997, he was admitted for the first time to our Department with a two month history of fever (maximum body temperature 39°C), chest pain, 5-kg weight loss and malaise. Physical examination revealed a pale, malnourished man, with body temperature of 36.8° C, arterial blood pressure 140/100 mm Hg, regular pulse rate of 100/minute, right pleural effusion, pericardial friction rub, slight hepatomegaly without lymphadenopathy and slight pedal edema. Laboratory tests showed anemia, white blood cell count 4.1 x 104, erythrocyte sedimentation rate 80 mm/h, C- reactive protein 152 mg/l, fibrinogen 4.4 g/l, blood urea nitrogen 38.3 mmol/l, serum creatinine concentration 284 m mol/l, potassium 6.3 mmol/l, calcium 2.5 mmol/l, phosphate 2.4 mmol/l. His liver enzyme levels were normal. In addition to febrile status, a rapid deterioration of the graft function developed and hemodialyses were started on April, 4. Despite intensive investigation, the cause of fever could not be found: repeated viral serology test for CMV, HSV, EBV, HIV remained negative; sputum, urine and blood cultures were negative including stains for acid-fast bacilli. On April, 9th severe pancytopenia ensued and bone biopsy was done. The bone marrow biopsy revealed granuloma with giant cells, partially necrotized and tuberculous bacilli by acid-fast stain. It can be concluded that pancytopenia due to tuberculosis should be added to the differential diagnosis of pancytopenia in renal graft recipients. Therefore, early bone marrow biopsy is recommended if fever of unknown origin and pancytopenia develop in renal transplant patients.